Living with endemic SARS-CoV-2 isn’t the same as ‘back to normal’

As provincial governments remove vaccine passport requirements and other public health measures, elected officials and public health leaders have invoked a transition from the SARS-CoV-2 pandemic to a time of endemic SARS-CoV-2, and have talked about “learning to live with the virus.” Some of this language, without doubt, is aimed at mollifying those who have engaged in protests against vaccine mandates and public health measures.

These officials have not, however, discussed in meaningful ways what “endemic SARS-CoV-2” and “living with the virus” truly mean in terms of our daily lives. They have also not meaningfully discussed what measures may be required to limit the adverse impacts of future variant waves or local outbreaks. It is important for the public to be clear on what living with endemic SARS-CoV-2 means to avoid false hope and inappropriate expectations that will make it difficult to respond to subsequent surges of SARS-CoV-2 transmission.

An endemic virus refers to one that is in common circulation in the population; in other words, it’s with us for good. Endemic viruses include influenza, human papillomavirus and the viruses that cause common colds. But, when SARS-CoV-2 becomes endemic it does not mean that the virus will behave any differently or will cause less severe illness. Additional variants may still emerge. People – particularly those insufficiently vaccinated, but also some who are immunized – will regularly become infected. A small but important number of these individuals will develop severe disease, and some will die. Others will develop prolonged post-COVID syndrome. The virus will remain a threat to individuals’ health and will continue to consume health-system resources. Variant waves or local outbreaks will continue to stretch health-care system capacity and may impair hospitals’ ability to provide care for patients with COVID and with non-COVID conditions.

Living with the virus does not mean that we will be able to live as we did before the pandemic began. Rather, we need to think about how we can successfully live with the virus to limit its impact on our daily lives while also avoiding unnecessary severe illness, deaths and health-system disruption.

Most endemic viruses infrequently cause severe illness, but SARS-CoV-2 has shown itself to be more infectious and more lethal than other endemic viruses. “Living with the virus” will require the best use of strategies to limit unnecessary mortality and strain on health-care systems. This includes continued public health measures as well as behaviours from private citizens to limit the probability of transmission.

Coping with an endemic SARS-CoV-2 virus also will require maximal uptake of vaccines in the global population. Vaccines decrease the probability of infection and severe disease. Countries that are likely to do well as public health measures are lifted, like Denmark, have much higher uptake of third vaccine doses than Canada. We need to increase the number of children with two doses, and adults with three, before we should think about relaxing public health measures. This means getting vaccines to the people using effective strategies like workplace- and school-based vaccine clinics. We need to aggressively combat sources of anti-vaccine disinformation. Rather than abandoning vaccine passports, strengthening programs to require a third dose to access some public spaces may be a better approach – at least until more eligible Canadians receive a booster.

These strategies should be used worldwide, along with aid programs to improve vaccine accessibility in low- and middle-income countries, as vaccine uptake across the world is key to limiting the emergence of variants.

Regulatory authorities will need to maintain the ability to rapidly evaluate and license new, effective SARS-CoV-2 vaccines and therapeutics. Governments and nongovernmental organizations should ensure that equitable distribution plans are in place to ensure that newly licensed vaccines and therapeutics get to those who need them.

“Living with the virus” will include continued public health measures.

Hospitals will need to be adequately resourced to build in surge capacity. The health-care workforce has experienced substantial attrition because of occupational stresses during the pandemic. Governments will need to rebuild workforce capacity, address burnout and moral injury experienced by health-care workers and make investments to ensure that hospital occupancy is maintained at sufficiently low levels to effectively cope with SARS-CoV-2 outbreaks or waves that may occur with novel variants.

Governments need to address the societal inequities that drove SARS-CoV-2 transmission amongst immigrants and those with unstable housing and employment. Non-medical interventions such as paid sick leave, leave to care for sick family members, isolation housing and financial supports will mitigate transmission of endemic SARS-CoV-2.

Finally, we need to address the issues of pandemic fatigue, and specifically attempt to remedy some of the issues that have led disenfranchised individuals to actively resist public health measures. As restrictions ease, authorities may still need to enact targeted, local public health measures to respond to new waves and outbreaks. This will test the patience and goodwill of a population that has already lived through two years of restrictions. While Canadians may be known for their generosity and politeness, the pandemic has led many Canadians to treat each other poorly based on their perspectives about the pandemic. We need to be kinder – and to better care for each other’s interests – on a daily basis.

Countries like Denmark are better prepared than Canada to deal with endemic SARS-CoV-2. They have higher vaccine uptake, the population is more adherent to public health advice (without even needing mandates), and the population may be more communally minded. We do need to ease public health measures sometime. But Canadians should not let the desire to get back to normal lead us to prematurely declare that it’s time to live with the virus without taking steps to ensure that we, as a society, can live with it successfully. The alternative is that people will continue to needlessly die from it.

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  • Richard Fralick says:

    Thank you Dr. McRae for your thoughtful piece on living successfully with endemic SARS-CoV-2. You have spelled out exactly what the public needs to know about the necessary steps to make this work.

  • Timothy Sly says:

    An excellent summary of the present situation. Thank you Dr. McRae for attempting to bring clarity and reality into the disturbingly-confused scenario presented to the public by misguided commentators. Ideology and populism appear to trump evidence more than ever. (At last an appropriate use of the “T” word!)


Andrew McRae


Andrew McRae is an emergency physician in Calgary, and an associate professor of Emergency Medicine and Community Health Sciences at the University of Calgary. He is a former member of the Alberta Health Services COVID-19 Scientific Advisory Group.

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